Med SURG HESI Final RN V2 (LATEST UPDATE)
Actual Exam | Complete Q&A with Rationales –
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Cardiovascular & Respiratory Disorders
Q1: The nurse is caring for a client admitted with heart failure who is receiving
furosemide (Lasix) IV. Which assessment finding is the best indicator that the
medication is achieving the desired therapeutic effect?
A. Weight loss of 2 pounds since admission
B. Blood pressure decreased from 140/90 to 120/80
C. Client reports reduced shortness of breath
D. Urine output of 100 mL over the past hour [CORRECT]
Correct Answer: D
Rationale: The primary action of loop diuretics like furosemide is to promote diuresis,
reducing fluid overload. While weight loss and symptom relief are eventual goals, the
most immediate and objective indicator of the drug’s pharmacological effect is adequate
urine output. You should look for a minimum of 30 mL/hour to ensure the kidneys are
perfused and responding to the medication.
Q2: A client with a history of coronary artery disease reports chest pain radiating to the
left arm. The nurse administers nitroglycerin 0.4 mg sublingually. What is the most
critical intervention the nurse must implement prior to giving this medication?
A. Check the client’s blood pressure
B. Obtain a 12-lead electrocardiogram
C. Elevate the head of the bed to 45 degrees
D. Assess for allergies to aspirin [CORRECT]
Correct Answer: A
Rationale: Nitroglycerin is a potent vasodilator that can cause severe hypotension. It is
standard safety practice to check the blood pressure before administration; if the
systolic pressure is below 90 mmHg (or sometimes 100 mmHg depending on facility
protocol), you must hold the medication and call the provider. Getting the ECG is
important, but safety comes first to prevent passing out or further cardiac compromise.
Q3: The nurse is assessing a client 2 days after a total knee replacement. The client
suddenly complains of chest pain and dyspnea. Which vital sign change would most
strongly suggest a pulmonary embolism (PE)?
,A. Temperature of 100.4°F (38°C)
B. Blood pressure of 160/90 mmHg
C. Respiratory rate of 32 breaths/minute
D. Heart rate of 110 beats/minute [CORRECT]
Correct Answer: D
Rationale: While tachypnea is common in PE, sudden onset tachycardia is often the
earliest and most reliable sign of a massive clot causing ventilation-perfusion mismatch
and cardiac stress. The body tries to compensate for the drop in oxygen by pumping
faster. Always look for the sudden spike in heart rate combined with respiratory distress
in a post-op surgical client.
Q4: A client is admitted with a diagnosis of deep vein thrombosis (DVT) and is
prescribed heparin infusion. The nurse reviews the laboratory results. Which value
would require the nurse to hold the heparin and notify the provider?
A. Platelet count of 150,000/mm³
B. aPTT of 90 seconds [CORRECT]
C. Prothrombin time (PT) of 12 seconds
D. Hemoglobin of 12 g/dL
Correct Answer: B
Rationale: The therapeutic range for aPTT when treating DVT is usually 1.5 to 2.5 times
the control value (roughly 60-80 seconds). An aPTT of 90 seconds puts the client at
high risk for spontaneous bleeding. You must hold the dose to prevent hemorrhage. A
platelet count of 150,000 is normal, and PT is primarily monitored for Coumadin
(warfarin), not heparin.
Q5: The nurse is caring for a client with a chest tube connected to a water-seal drainage
system. During assessment, the nurse notes continuous bubbling in the water-seal
chamber. What is the priority nursing action?
A. Clamp the chest tube near the client
B. Check for loose connections or system leaks [CORRECT]
C. Encourage the client to cough and deep breathe
D. Document the finding and continue monitoring
Correct Answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak in the
system. This could be from a loose connection or, worse, a disruption in the pleural
space. You need to find the source of the leak immediately. Clamping the chest tube is
dangerous unless you are changing the system or preparing for removal, as it can
cause tension pneumothorax. Coughing usually causes intermittent bubbling, not
continuous.
, Q6: A client with endocarditis is scheduled for a dental extraction. The nurse anticipates
that the provider will prescribe prophylactic antibiotics for which reason?
A. To prevent infective endocarditis caused by bacteremia [CORRECT]
B. To reduce the risk of a systemic allergic reaction
C. To treat an existing periodontal infection
D. To prevent post-extraction bleeding complications
Correct Answer: A
Rationale: Dental procedures can cause bacteria to enter the bloodstream (bacteremia).
In clients with damaged heart valves or a history of endocarditis, these bacteria can
colonize the heart lining, leading to infective endocarditis. Prophylactic antibiotics are
given specifically to prevent this colonization. This is a classic "gold standard"
prevention strategy we teach in Med-Surg.
Q7: The nurse is teaching a client about pericarditis. Which statement by the client
indicates a need for further teaching?
A. "I should expect the pain to worsen when I take a deep breath."
B. "Lying flat might increase my pain, so I will sit up and lean forward."
C. "I can take ibuprofen to help with the inflammation."
D. "The sharp chest pain is caused by blocked coronary arteries." [CORRECT]
Correct Answer: D
Rationale: Pericarditis pain is caused by inflammation of the pericardial sac, not by
coronary artery blockage (which causes angina). The hallmark of pericarditis is sharp,
pleuritic pain that worsens with inspiration (friction rub) and is relieved by sitting up and
leaning forward (reduces pressure on the sac). The client is confusing the
pathophysiology with that of an MI.
Q8: A client presents to the Emergency Department with sudden onset of severe
"tearing" abdominal pain radiating to the back. The nurse observes a significant
difference in blood pressure between the left and right arms. What condition should the
nurse suspect?
A. Acute pancreatitis
B. Ruptured spleen
C. Dissecting aortic aneurysm [CORRECT]
D. Acute myocardial infarction
Correct Answer: C
Rationale: Tearing pain radiating to the back, coupled with a difference in blood
pressure between arms, is a classic sign of an aortic dissection. The dissection can
occlude the subclavian artery, leading to the pressure discrepancy. This is a "failure to
rescue" situation—if you miss this, the patient can rupture and die rapidly. Pancreatitis
Actual Exam | Complete Q&A with Rationales –
Pass Guaranteed - A+ Graded
Cardiovascular & Respiratory Disorders
Q1: The nurse is caring for a client admitted with heart failure who is receiving
furosemide (Lasix) IV. Which assessment finding is the best indicator that the
medication is achieving the desired therapeutic effect?
A. Weight loss of 2 pounds since admission
B. Blood pressure decreased from 140/90 to 120/80
C. Client reports reduced shortness of breath
D. Urine output of 100 mL over the past hour [CORRECT]
Correct Answer: D
Rationale: The primary action of loop diuretics like furosemide is to promote diuresis,
reducing fluid overload. While weight loss and symptom relief are eventual goals, the
most immediate and objective indicator of the drug’s pharmacological effect is adequate
urine output. You should look for a minimum of 30 mL/hour to ensure the kidneys are
perfused and responding to the medication.
Q2: A client with a history of coronary artery disease reports chest pain radiating to the
left arm. The nurse administers nitroglycerin 0.4 mg sublingually. What is the most
critical intervention the nurse must implement prior to giving this medication?
A. Check the client’s blood pressure
B. Obtain a 12-lead electrocardiogram
C. Elevate the head of the bed to 45 degrees
D. Assess for allergies to aspirin [CORRECT]
Correct Answer: A
Rationale: Nitroglycerin is a potent vasodilator that can cause severe hypotension. It is
standard safety practice to check the blood pressure before administration; if the
systolic pressure is below 90 mmHg (or sometimes 100 mmHg depending on facility
protocol), you must hold the medication and call the provider. Getting the ECG is
important, but safety comes first to prevent passing out or further cardiac compromise.
Q3: The nurse is assessing a client 2 days after a total knee replacement. The client
suddenly complains of chest pain and dyspnea. Which vital sign change would most
strongly suggest a pulmonary embolism (PE)?
,A. Temperature of 100.4°F (38°C)
B. Blood pressure of 160/90 mmHg
C. Respiratory rate of 32 breaths/minute
D. Heart rate of 110 beats/minute [CORRECT]
Correct Answer: D
Rationale: While tachypnea is common in PE, sudden onset tachycardia is often the
earliest and most reliable sign of a massive clot causing ventilation-perfusion mismatch
and cardiac stress. The body tries to compensate for the drop in oxygen by pumping
faster. Always look for the sudden spike in heart rate combined with respiratory distress
in a post-op surgical client.
Q4: A client is admitted with a diagnosis of deep vein thrombosis (DVT) and is
prescribed heparin infusion. The nurse reviews the laboratory results. Which value
would require the nurse to hold the heparin and notify the provider?
A. Platelet count of 150,000/mm³
B. aPTT of 90 seconds [CORRECT]
C. Prothrombin time (PT) of 12 seconds
D. Hemoglobin of 12 g/dL
Correct Answer: B
Rationale: The therapeutic range for aPTT when treating DVT is usually 1.5 to 2.5 times
the control value (roughly 60-80 seconds). An aPTT of 90 seconds puts the client at
high risk for spontaneous bleeding. You must hold the dose to prevent hemorrhage. A
platelet count of 150,000 is normal, and PT is primarily monitored for Coumadin
(warfarin), not heparin.
Q5: The nurse is caring for a client with a chest tube connected to a water-seal drainage
system. During assessment, the nurse notes continuous bubbling in the water-seal
chamber. What is the priority nursing action?
A. Clamp the chest tube near the client
B. Check for loose connections or system leaks [CORRECT]
C. Encourage the client to cough and deep breathe
D. Document the finding and continue monitoring
Correct Answer: B
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak in the
system. This could be from a loose connection or, worse, a disruption in the pleural
space. You need to find the source of the leak immediately. Clamping the chest tube is
dangerous unless you are changing the system or preparing for removal, as it can
cause tension pneumothorax. Coughing usually causes intermittent bubbling, not
continuous.
, Q6: A client with endocarditis is scheduled for a dental extraction. The nurse anticipates
that the provider will prescribe prophylactic antibiotics for which reason?
A. To prevent infective endocarditis caused by bacteremia [CORRECT]
B. To reduce the risk of a systemic allergic reaction
C. To treat an existing periodontal infection
D. To prevent post-extraction bleeding complications
Correct Answer: A
Rationale: Dental procedures can cause bacteria to enter the bloodstream (bacteremia).
In clients with damaged heart valves or a history of endocarditis, these bacteria can
colonize the heart lining, leading to infective endocarditis. Prophylactic antibiotics are
given specifically to prevent this colonization. This is a classic "gold standard"
prevention strategy we teach in Med-Surg.
Q7: The nurse is teaching a client about pericarditis. Which statement by the client
indicates a need for further teaching?
A. "I should expect the pain to worsen when I take a deep breath."
B. "Lying flat might increase my pain, so I will sit up and lean forward."
C. "I can take ibuprofen to help with the inflammation."
D. "The sharp chest pain is caused by blocked coronary arteries." [CORRECT]
Correct Answer: D
Rationale: Pericarditis pain is caused by inflammation of the pericardial sac, not by
coronary artery blockage (which causes angina). The hallmark of pericarditis is sharp,
pleuritic pain that worsens with inspiration (friction rub) and is relieved by sitting up and
leaning forward (reduces pressure on the sac). The client is confusing the
pathophysiology with that of an MI.
Q8: A client presents to the Emergency Department with sudden onset of severe
"tearing" abdominal pain radiating to the back. The nurse observes a significant
difference in blood pressure between the left and right arms. What condition should the
nurse suspect?
A. Acute pancreatitis
B. Ruptured spleen
C. Dissecting aortic aneurysm [CORRECT]
D. Acute myocardial infarction
Correct Answer: C
Rationale: Tearing pain radiating to the back, coupled with a difference in blood
pressure between arms, is a classic sign of an aortic dissection. The dissection can
occlude the subclavian artery, leading to the pressure discrepancy. This is a "failure to
rescue" situation—if you miss this, the patient can rupture and die rapidly. Pancreatitis
